F. Azzolini

A randomized clinical trial comparing 22G and 25G needles in endoscopic ultrasound-guided fine-needle aspiration of solid lesions

BACKGROUND AND STUDY AIMS The study aimed to investigate whether the 25G needle is superior to the 22G needle when used in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of solid lesions. PATIENTS AND METHODS The study was a single-center randomized clinical trial. The setting was a tertiary referral hospital, where EUS-FNA of solid lesions was assisted by an on-site cytopathologist, who was blinded to the needle size. The main end point was the number of passes performed to obtain adequate samples. Crossover to the other type of needle was allowed after five passes, or when the gastroenterologist experienced difficulties in puncturing the lesions. RESULTS A total of 129 solid lesions were randomized and data regarding 127 lesions were analyzed. The mean number of passes was 3.7 (± 1.9) in the 22G needle group and 3.8 (± 2) in the 25G needle groups (difference of means: 0.1; 95% CI: -0.59 to 0.79). Fifty-eight of 63 (92.1%) and 60/64 samples (93.7%) in the 22G and 25G needle groups respectively were adequate (difference: -1.6%; 95%CI: -12.1% to 8.9%). Crossover to the other type of needle was performed in 11/63 (17.5%) and in 12/64 (18.7%) lesions in the two groups respectively (difference: -1.2%; 95%CI: -16.2% to 13.8%). A crossover to the 25G needle was successfully performed in four masses in the uncinate process; these lesions were difficult to puncture using the 22G needle. CONCLUSIONS Our study failed to demonstrate that the 25G is more effective than the 22G needle in EUS-FNA of solid lesions. However, targeting of lesions in the distal duodenum may be simplified by using the 25G needle.

Ga-68 DOTATOC PET, endoscopic ultrasonography, and multidetector CT in the diagnosis of duodenopancreatic neuroendocrine tumors: a single-centre retrospective study.

Purpose: In this report, we compared endoscopic ultrasonography (EUS), multidetector CT (MDCT), and Ga-68 DOTATOC PET/CT in patients with neuroendocrine tumors (NETs). We report our experience with use of these methods in patients suspected to have duodenopancreatic primitive NET. Methods: Nineteen consecutive patients (mean age, 56; 21–80), who underwent both Ga-68 DOTATOC PET/CT and EUS between March 2007 and November 2008 were retrospectively included in the study (16 underwent MDCT). Suspicion of NET was confirmed by EUS-FNA and/or surgery. Operative characteristics of PET, EUS, and MDCT were compared. Results: Twenty-three neuroendocrine lesions were diagnosed in 13/19 patients. EUS, PET, and MDCT correctly identified as affected 13/13 (100%), 12/13 (92%), and 10/11 (91%) patients, respectively. On a lesion basis, EUS, PET, and MDCT identified correctly as NETs 22/23 (96%), 20/23 (87%), and 13/18 (72%) lesions (P = 0.08 EUS vs. CT). Both on a patient and on a lesion basis, specificity was 67%, 83%, and 80% for EUS, PET, and MDCT, respectively. Conclusions: EUS, Ga-68 DOTATOC PET, and MDCT seem to have comparable accuracy in diagnosis of duodenopancreatic NET and their combination may allow an optimal preoperative diagnosis.

The natural history of upper gastrointestinal subepithelial tumors: a multicenter endoscopic ultrasound survey.

Goals To evaluate the natural course of <3-cm upper gastrointestinal subepithelial tumors by endoscopic ultrasound (EUS) and to determine the appropriate timing for EUS follow-up. Background Subepithelial tumors (SETs) can range from benign lesions to tumors with malignant behavior or potential to become malignant such as gastrointestinal stromal tumors (GISTs). EUS is considered a valuable tool for their evaluation as it estimates the exact size and layer of origin, and also additional morphologic features that can suggest the diagnosis. For high surgical risk patients and when no worrisome EUS features are seen, EUS surveillance of subepithelial tumors is often used. Methods Fifty-one patients (mean age, 61.2±11.8 y; median, 63 y) with asymptomatic <3-cm SETs of second and fourth echolayer were followed for a mean period of 29.7 months (range, 3 to 84; median, 23 mo) in 3 tertiary care institutions. Evaluation included location, echolayer, tumor diameter, internal echo pattern, and outer margin of lesions by EUS. EUS was performed by using miniprobes, radial and linear echoendoscopes. Results Follow-up revealed increase in size and/or change in echogenic features in 7/51 (13.7%) patients. Surgical follow-up was available for 3 of 7 of these patients. Two of the fourth layer SETs, which had both increase in size and change in echogenicity were found to be GISTs (+c-kit). Conclusions The majority of <3-cm SETs does not change during a median of 23 months. The change in echogenicity and increase in size may indicate a GIST.

Proposal of a new clinical index predictive of endoscopic severity in ulcerative colitis.

Assessment of disease activity by clinical parameters in ulcerative colitis is still controversial. Different clinical indexes have been proposed. Colonoscopy provides detailed information on mucosal damage. The aim of this study was to identify, among 21 clinical and laboratory parameters, which were predictive of endoscopic activity. We included 137 consecutive patients with ulcerative colitis who underwent colonoscopy, clinical examination, and blood tests within 4 weeks. Endoscopic severity was recorded using a simple score (range, 0–30). The multiple stepwise regression coefficient of each significant variable predictive of mucosal damage was used to develop a new activity index predictive of endoscopic appearance (Endoscopic–Clinical Correlation Index; ECCI). We tested the ability of our score to discriminate patients with severe endoscopic disease, calculating the area under the receiver operator characteristic curve, and we compared it to activity indexes proposed by other authors. Endoscopic severity was significantly influenced by four parameters: bloody stool, nocturnal bowel movements, body temperature >37.5°C, and serum albumin. The new scoring system was calculated as ECCI = {[serum albumin × (−26)] + (bloody stool × 17) + (nocturnal bowel movements × 16) + [fever (0 or 1) × 39]} + 107. The ECCI accurately identified patients with severe endoscopic disease in our sample (sensitivity = 81%, specificity = 95%). In conclusion, the ECCI should be useful in clinical practice because it is simple and strongly related to endoscopic activity.

Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps).

BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting. METHODS We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2-5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months. RESULTS We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12-24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively. CONCLUSIONS Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.

Endoscopic submucosal dissection of an unusual flat rectal neoplasm

A 63-year-old woman was admitted to our gastroenterology unit to undergo a screening colonoscopy, scheduled for faecal occult blood test positivity. During the procedure, a flat, rectal granular lesion was found. With the use of magnification and narrow band image (NBI) technology, the lesion was diagnosed as a laterally spreading tumour (LST), granular mixed type, 30 mm in maximum diameter (figure 1). The pit pattern was unclassifiable and vascular pattern was similar to the type IV of the classification proposed by Inoue regarding the microvasculature pattern of the oesophagus for diagnosis and evaluation of the squamous cell carcinoma. The …

Submucosal tunneling endoscopic resection of a gastric gastrointestinal stromal tumor

A 64-year-old man was admitted to our hospital for endoscopic resection of a gastrointestinal stromal tumor (GIST) of the gastric antrum. The submucosal tumor had been previously observed during an esophagastroduodenoscopy, which revealed a protruded lesion in the greater curve of the gastric antrum. The subsequent endoscopic ultrasound showed that the tumor was large (20mm), arose from the muscularis propria layer, and showed a persistent enhancement after infusion of SonoVue (Bracco, Milan, Italy). The contextual fine-needle aspiration, performed with a 19 gauche Echotip Ultra (Cook Medical Inc. Limerik, Ireland), showed solid clusters of spindle cells, which were positive for CD34 and CD117, and therefore diagnostic for GIST. On this basis, a submucosal tunneling endoscopic resection (STER) was performed with a HybridKnife T-Type (ERBE, Tubingen, Germany) and IT-Knife 2 (Olympus, Tokyo, Japan). A submucosal tunnel was created through a longitudinal incision of the mucosal layer. After reaching the tumor, the lesion was carefully dissected from the layers of the gastric wall and subsequently removed (▶Fig. 1 a, b). At the end of the procedure, the mucosal defect was closed with Instinct clips (Cook Medical Inc.) (▶Fig. 1 c). The STER procedure was completed, without adverse events, in about 150 minutes (▶Fig. 1d, ▶Video1). The histopathological examination showed a low risk GIST [1] that was positive for smooth muscle actin, CD34, and CD117, and negative for S-100 protein. The mitotic activity was 1 mitoses per 50 HPF (▶Fig. 2). The patient was discharged after three days uneventful, and was referred for endoscopic follow-up. The endoscopic and echoendoscopic follow-up performed after 1 year did not reveal any residual or recurrent tumor. E-Videos

Endoscopic ultrasound image of hydatid membranes in the common bile duct.

A 25-year-old Caucasian male was admitted to our Department or abdominal pain, fever, jaundice and cholestasis. Transabdomnal ultrasonography showed a cyst in the left lobe of the liver, inimal ascites, dilatation of the main biliary duct and biliary ludge in the gallbladder. The patient underwent endoscopic ultrasonography (EUS) that howed an “multi-layered circular image” in the main bile duct (Fig. , arrows 1, 2, 3). The hypothesis of Echinococcosis seemed unlikely iven that the patient had no risk factors and that our area is not ndemic. An endoscopic retrograde pancreato-cholangiography with phincterotomy was performed with removal of a collapsed cyst ithin the common bile duct (Fig. 2). Histopathologic examination as diagnostic for hydatid cyst. This is the second case of EUS documentation of hydatid embranes in the common bile duct (CBD), and the rupture f an hydatid cyst in the biliary tract is a rare, but serious omplication of Echinococcosis. In the previous case reported floatng membranes were described in the CBD [1]. In the present ase we observed a multi-layered circular “gut wall like” image hich may raise suspicion for the presence of hydatid cyst.

Glomus Tumor of the Stomach: GI Image

A 70-year-old female presented to our attention with an incidental finding, of a gastric mass, during videolaparoscopic cholecystectomy; the surgeon described a mass forming lesion within the gastric wall that did not erose the serosa. The patient underwent different gastroscopies, and during the last gastroscopic control, the endoscopist found a significant increasement of the well-known mass (2 cm in diameter), located in the gastric antrum nearby the pylorum laying in the greater curvature. According to the macroscopic findings, our first diagnostic hypothesis was of GIST. Then, an EUSFNA (Fig. 1) was performed with on-site cytopathology assistance to evaluate the adequacy of material. The cytopathology smear showed a population of uniform, round epithelioid cells, with relatively small nucleoli and variable eosinophilic cytoplasm, which stained for smooth muscle actin but were negative for desmin, chromogranin, synapthophisin, and keratin (Fig. 2). A final cytological diagnosis of glomus tumor (GT) of the stomach was obtained. The patient underwent a CT scan (Fig. 3) that confirmed the presence of a hyperdense lesion of about 14 mm, in the absence of lymphadenomegaly or metastatic disease. There weren’t any contraindications for surgery, so we decided to perform a gastric laparoscopic wedge resection of the lesion (Fig. 4). Laparoscopy is a good minimally invasive technique in case of small and benign tumors, which allowed us to discharge the patient in the fourth

Malignant intraductal papillary mucinous neoplasm of the pancreas with gastric and duodenal fistulas

A 76-year-old man was admitted to our service because of abdominal pain and weight loss. Twenty years earlier, the patient had experienced indeterminate acute pancreatitis with consequent pancreatic pseudocyst in followup. Abdominal magnetic resonance imaging showed a contrast-enhanced 7-cm solid mass with cystic component involving the pancreatic head and isthmus and inducing gastric compression, dilatation of the main pancreatic duct, and small cysts in the pancreatic tail (A). Contrast harmonic EUS confirmed the mixed echopattern pancreatic mass with contrast enhancement of the solid component and disruption of the duodenal bulb wall close to the lesion. Moreover, the main pancreatic duct was dilated, and the common bile duct appeared normal. Therefore, FNA with a 22G needle was performed (B). Upper endoscopy revealed a 4-cm gastric